139 Alamosa Drive Lot 11DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
- *NOTE: Issued in Compliance With Article I I of G.S. Chapter 130a
P P
S nitary Sewage Systems Permit .Number
Name /�/jtj �' 1r% a -l/ fl/r�/.v fP Date —�S /j N2 6103
Location /U,70�;%/f-
,UGG v,�//�
Subdivision Name � %�
Lot No. �.� Sec. or Block No.
Lot Size
House
Mobile Home Business Speculation
No. Bedrooms ��
No. Baths
-
- No. in Family t� _
Garbage Disposal
Auto Dish Washer
YES ❑ NOp�
YES NO
❑
-
Specifications for System: .-
Auto Wash Machine
YES NO
❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
Improvements permit by
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
w,
r
i
-J
Certificate of Completion Date � S
`The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested By �4 ._ AJ Business Phone 9 9 f ol- y 0 U
2. Address PD /ADX /l vANLE I��C �.700Ito
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy. Conventional `Other Type –
Ground Absorption
c) Sub -Division) -A �y Z N r1_A Sec./ S10- F Lot No. -'9 /)Jo S,4
5. System used to serve what type facility: House Mobile `Homed Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions / VX7O
Bed Rooms 3 Bath Rooms %�' Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount,Rf waste daily (24 hours)
7. Number and type of water -using fixtures:
commodes 2 urinals garbage disposal
lavatory showers washing machine
`- C 5
„vd'shwashe� inks `' Q –
8. a) Typ waters pply. Ilubli0 a Community ' `' I
I b) Has the wate y system been ap roved? Yeses No S 0 0 W N C
9. a)-Rm erty Dim sions �
r z b) Can area des grated to building site C –
c Sew ge Dispo al Ca r•�4ractor , - --
,l� 13
10. Do you nticipate a `' ' s or expans ons of the facility this swage sys em is intended to serve
Wham e? j' rn
17 9 his- —P c fy that the info rrrtLon is c cert -t a best o my knowledge.
1 1
o � g - �' `I r I I { I I Ow6r S nd 5
WNER I r$OLELY RE-bPONSIBCE FOR COMPLIANCE WI H ALL S TE AND LOCAL LAW
5 All w 5Wys for ro
erections to p operty: C
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Name—
Address
Pe4
FACTORR
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size
AREA 3 ARFA d
AREA 1 AREA 2
1) Topography/ Landscape Position
S
S
S
S
PS
PS
PS
U
U
U
�) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
U
U
U
3) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
PS
PS
PS
U
U
U
1) Soil Depth (inches)
S
S
S
PS
PS
PS
U
U
U
i) Soil Drainage: Internal
S
S
S
PS
PS
PS
U
U
U
External
S
S
S
PS
PS
PS
U
U
U
i) Restrictive. Horizons
Available Space
S
S
PS
S
PS
S
PS
U
U
U
Q Other (Specify)
S
S
S
S
PS
PS
PS
PS
Ute-
U
U
U
1) Site Classification
R>.
U—UNSUITABLE
Recommendations/Comments: '0 Z
S—SUITABLE 45S—Provisionally Suitable
Described by /� GTitle/'N Date
SITE DIAGRAM
DCHD (6.82)